Posttraumatic stress disorder (PTSD) is a complex syndrome , which affects mental, emotional, behavioral, and physical aspects of health. According to Otis and colleagues in a 2010 study, PTSD has been found to coexist in 34–50 % of veterans referred for treatment of chronic pain [3]. Persistent hyper arousal and activation of the fight or flight response in these patients results in dysregulation of the autonomic nervous system and other related neurophysiologic functions [4, 5]. Disruption of these systems in patients with PTSD has been shown to be associated with the multiple poor health outcomes including: metabolic disease, cardiovascular disease, asthma, cancer, back pain, peripheral vascular disease, gastrointestinal problems, and thyroid disorders. Polypharmacy and the risks associated with taking multiple medications are common in these patients because of their multiple comorbidities and symptoms, such as hypertension, headaches, sleep disorders, and nightmares [6].

James Reston, a New York Times reporter who accompanied President Nixon to China in 1971, introduced acupuncture to the public at large in the USA. Since then, awareness and use of acupuncture has increased throughout the US populace in general and among members of the military. In 2007, Smith et al. reported that active duty military members and veterans reported seeking treatment for acupuncture and other complementary and alternative therapies in order to avoid side effects from medications and to learn health strategies to prevent and treat the underlying cause of disease rather than focus on management of the symptoms of disease [7].

The growing use of complementary and alternative medicine (CAM) modalities was reflected in a 2013 article published in The Journal of Complementary and Alternative Medicine, which reported that the overall use of CAM, including acupuncture by active duty military members is higher (44.5 %) than in comparable civilian surveys (38.3 %), with the vast majority of treatments sought outside of the military health care system [8]. Simultaneously, research as to the mechanisms and effectiveness of acupuncture has grown both in quantity and quality [9].

A recent meta-analysis and systematic review on acupuncture for trauma spectrum response (a common symptomatic and functional spectrum of physical, cognitive, psychological, and behavioral effects seen in combat veterans who have experienced psychological and/or physical trauma), found acupuncture to be effective for headaches, and promising for chronic pain , sleep disturbances, anxiety and depression [10]. More specific to PTSD, a recent systematic review of randomized controlled trials (RCTs) and prospective clinical trials for PTSD, found that, based on one high-quality RCT and a meta-analysis, the effectiveness of acupuncture was statistically superior to waitlist control. No statistical difference was found between the effectiveness of acupuncture and cognitive behavioral therapy . Acupuncture plus moxibustion was shown to be superior to oral selective serotonin reuptake inhibitors (SSRI) therapy for PTSD in the meta-analysis [11].

Although high-quality controlled studies, meta-analysis and systematic reviews, are important in determining the effectiveness of a therapy, case reports help us to see the faces and stories of those who seek and benefit from the availability of acupuncture and other holistic therapies, which have been used since ancient time to treat wounds and disorders of the spirit as well as those of the body and mind.

Together with other military medical acupuncturists I have found that active duty military patients and veterans are very accepting of acupuncture [12]. Indeed, many of my patients have reported paying out of pocket for acupuncture prior to finding out that it was available in our pain management clinic.

It is well known that mental health disorders such as depression and anxiety are present in approximately 60 % of patients presenting for treatment of chronic pain [13]. Advanced imaging studies have revealed many commonalities in the neural processing of chronic pain and areas of the brain where emotional “suffering” is processed [14]. Because many of our pain patients present with a history of trauma and a diagnosis of PTSD, it is common to address this disorder in our pain patients (in addition to their chronic pain complaint) within the holistic approach afforded by acupuncture.

Although some patients request referral for acupuncture treatment to avoid medications, procedures, and surgery, the majority of our patients are referred for acupuncture after all the available and applicable conventional therapies have failed to significantly improve their condition(s). The latter is true for the patients in the following case reports.

A 21-year-old active duty female US Marine was referred to the pain clinic from orthopedics on a Friday afternoon with a complaint of severe low back pain and difficulty walking. Due to the severity of her complaints, she was admitted to the orthopedic service to rule out cauda equina syndrome. An urgent MRI showed no evidence of central spinal stenosis. Lumbar degenerative disc disease at the L4–5 and L5-S1 levels was mild with minimal neuroforaminal narrowing.

The patient had been brought to the pain clinic on a gurney. Pain medication consisted of intravenous (IV) morphine via a patient controlled analgesic device. Her history of present illness was significant for chronic remitting and relapsing low back pain since boot camp with no known trauma or initiating event. She had been seen in the pain clinic the previous year for an epidural steroid injection for right lower extremity leg pain and numbness in the L5-S1 distribution. Her leg pain had improved following the epidural steroid injection.

On physical exam, vital signs were within normal limits. Her pain was 9–10/10. The patient was 5 ft 4 in., and 120 lbs. She was able to move all of her extremities, but grimaced and moaned when asked to move her legs. Her back pain increased with any movement. Leg strength was 4/5 throughout all muscle groups both left and right with no asymmetry. Straight leg raises were negative for radicular pain but produced severe increase in her low back pain at 10–20 ° of elevation. Deep tendon reflexes were symmetrical. She had no sensory deficits.

The patient was unable to sit in the gurney or to roll to her side or abdomen. Three corpsmen were needed to assist in log rolling the patient to her side as any flexion or extension of her back resulted in cries of pain. No focal tenderness was found.

Initial conventional pain management treatment consisted of converting her IV morphine to oral long acting opioid equivalents, with short acting opioid for break through pain. A low dose of amitriptyline was started and given at bedtime both as a pain adjunct and to assist with sleep hygiene.

On the following Monday, a multidisciplinary meeting was convened to discuss the patient. Attendees included a pain management physician, an orthopedic surgeon, a psychiatrist, the health psychologist, a chaplain, a case manager, and a physical therapist. The psychiatrist proceeded to summarize the patient’s social history, which included sexual molestation as a child, and gang rape as a teenager, with the latter resulting in pregnancy. She had kept the child, who was being reared by relatives. She had subsequently joined the US Marine Corps.

A 29-year-old female first class Petty Officer with chronic low back pain, refractory to other therapies, was referred to the pain management acupuncture clinic. Her low back pain of approximately 3 years began after she was injured in the bombing of the USS Cole in October of 2000.

Her lumbar spine MRI was significant for L4–5 and L5-S1 degenerative disease with no central or neuroforaminal stenosis. Her constant low back pain averaged 5–7/10 and limited her ability to run. It was worsened by bending, twisting, and lifting anything over 15 pounds. She denied radicular symptoms, leg weakness, and bowel or bladder incontinence. She had undergone chiropractic treatments, physical therapy, and other conservative treatment, including nonsteroidal anti-inflammatory medications, muscle relaxants and opioids which did not significantly alleviate her pain and caused intolerable side effects. She had also undergone trigger point injections and diagnostic medial branch blocks to rule out facet mediated low back pain without benefit.

She had been evaluated by neurosurgery and was not felt to be a surgical candidate. She gave a history of having suffered significant burns of the face and hands at the time of the blast. Although scarring from the burns was not visible, the patient produced pictures which had been taken of her at the time of her treatment for the burns at Landstuhl Regional Medical Center in Germany. The patient was also followed for chronic PTSD related to the blast.

On physical exam, vital signs were within normal limits. Her pain VAS 6–7/10. Her affect and speech were flat, but responses were appropriate and no cognitive deficits were appreciated. She was observed to have a normal gait and stance. She had tenderness to palpation over her lumbar paraspinous region bilaterally and pain was increased with flexion of the lumbar spine to 45° and lumbar spine extension to 25°. No sensory, motor, or deep tendon reflex abnormalities were observed and exam of all other systems was within normal limits.

The patient is a 51-year-old officer. He reported last being well prior to his 2007–2008 Iraq deployment . During that deployment, the patient suffered a mild traumatic brain injury (mTBI) when a mortar barrage hit his base with about 10–15 rounds impacting near him. Diving for cover, the patient sustained shrapnel to his left knee but denied experiencing loss of consciousness (LOC) or posttraumatic amnesia. He did not seek immediate treatment.

Several other traumatic experiences occurred during that deployment, wherein the patient witnessed “death up close.” Perhaps the most traumatic experience the patient described was losing his friend to an improvised explosive device (IED). The patient was supposed to be on the convoy which took the life of his good friend and subordinate. “That should have been me,” the patient reported, noting that he asked his subordinate to attend the convoy so that he could go to lunch with a governmental organization.

Following his return home, the patient continued to experience marked guilt and recriminations. During the time when he was not at home, he worked nonstop, throwing himself into his work. To keep from thinking about things that he had seen during his deployment, the patient started drinking regularly, two or more drinks per night. He started to become depressed.

Symptoms of PTSD, chiefly, emotional numbing with memory loss, flashbacks, depersonalization and derealization, sleep disturbance, and hypervigilance, accompanied increasing guilt. He did not seek treatment and thought that by redeploying he might be able to make amends, particularly if he was killed in an act saving someone else. When the opportunity arose for another combat tour, this time to Afghanistan in 2012, the patient leaped at the chance.